Basic Information
| Provider Information | |||||||||
| NPI: | 1093224206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | MOEZZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD. | ||||||||
| Address2: | ATTN: MANAGED CARE DEPT. | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 PABLO ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338033818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632845020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2017 | ||||||||
| LastUpdateDate: | 07/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9286988 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 363L00000X | APRN9286899 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | ARNP9286988 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.